Managing Cesarean and Perineal Scar Pain After Delivery and Preventing a Perineal Tear
By Dr. Brook Orvis, PT, DPT, WCS, PRPC, CLT
Scar tissue is, unfortunately, an incredibly common byproduct of pregnancy and delivery, regardless of whether you have a cesarean or vaginal delivery. Perineal tears, or the tearing of the tissue between the vaginal and anal openings, occurs in approximately 70% of birthing people during delivery and is as high as 90% in women who are pregnant and giving birth for the first time. Cesarean deliveries are also incredibly common in the United States and occur in approximately one-third of deliveries.
With delivery and any sort of tearing that may occur during a vaginal delivery or the trauma from having a cesarean section comes scar tissue. And with scar tissue there is always the potential for discomfort or pain in the area where the trauma occurred. It is common for around 25% of people who have had a cesarean delivery and 10% of those who had perineal tearing during a vaginal delivery that there was pain at the area of the resulting scar tissue.
So, while scar tissue and pain doesn’t sound like a super fun result following childbirth, as a pelvic floor physical therapist there are tons of things that I go over with my clients during pregnancy as well as following delivery to help (hopefully!) prevent tearing from occurring in the first place and to help resolve the pain if it occurs.
The Different Layers of Tissue Affected During Cesarean Deliveries
During a cesarean section there are seven (!!!!) layers of tissue that your obstetrician cuts through in order to deliver your baby. This may help to explain why the recovery process can feel so challenging and why you may be having pain. Even though it’s a common procedure, it is still considered a major abdominal surgery!
- The skin is typically cut down low at the bikini line with a horizontal incision.
- Camper’s fascia (the fatty layer of tissue directly below the skin) is cut through horizontally.
- Scarpa’s fascia (the deeper membranous layer below Camper’s fascia) is cut through horizontally.
- The rectus sheath (fascia that encloses the multiple layers of the rectus abdominis muscles and helps to form the linea alba, or the line that goes down the middle of the abdominal muscles where diastasis recti can form) is cut horizontally.
- The rectus abdominis muscle (your six pack) is moved using blunt dissection (this layer is not cut through during surgery).
- The parietal peritoneum (a supportive layer that surrounds the outside of your internal organs to help provide lubrication and decrease friction between the organs) is cut through vertically.
- The uterus and the amniotic sac are cut using a horizontal incision.
...we don’t do enough to help prepare birthing people for how to take care of their bodies (and specifically their pelvic floor!) proactively during pregnancy and once the baby arrives.
Types of Perineal Tears
Perineal tears are incredibly common in both first-time parents as well as birthing people who have previously had a baby. A perineal tear is a tearing of the tissue between the vaginal and anal openings. There are different types or classifications of perineal tears:
1st Degree: involves the skin of the perineum and sometimes the urethra (where pee exits the body)
2nd Degree: involves the skin and muscle at the perineum and can extend deeper into the vaginal opening
3rd Degree: involves the tissues of the 1st and 2nd degree tears and extend into the anal sphincter. These tears are further classified as follows:
- 3A: <50% of the external anal sphincter is damaged
- 3B: >50% of the external anal sphincter is damaged
- 3C: all of the external anal sphincter is damaged and the internal anal sphincter is also damaged
4th Degree: the external and anal sphincters are damaged and the damage extends into the anal mucosa (the inner lining of the anus)
As a Duke Women’s Health Residency Trained and Board-Certified Women’s Health (WCS) and Pelvic Floor (PRPC) Physical Therapist, I work with everyone with a pelvic floor, including people that are pregnant and post-delivery who are wanting to prepare for their upcoming labor and delivery, to stay strong during their pregnancy, to address any aches or pains that come up during pregnancy, as well as to address any issues following the delivery of baby. If my many years of experience working with this patient population, and having gone through pregnancy and delivery myself, has taught me anything, it’s that we don’t do enough to help prepare birthing people for how to take care of their bodies (and specifically their pelvic floor!) proactively during pregnancy and once the baby arrives.
Recommendations on How to Help Reduce the Risk of Tearing During Delivery
- Use appropriate pushing mechanics during delivery!
Pushing during labor and delivery should actually not look like how it is portrayed in the movies, which is considered “purple pushing.” During delivery you want to make sure that, as best as you can, that you don’t strain. A technique that I like to teach my clients is something called making your “belly big, belly hard.” This is where you gently push your abdomen out and keep it pushed out as you blow out through your mouth as though blowing out birthday candles. This technique helps to lengthen your pelvic floor muscles and essentially get them the heck out of the way so that as your uterus contracts during labor that your baby can descend down the birth canal.
2. Do perineal massage leading up to and during your delivery.
Perineal massage stretches the muscles at the vaginal opening, specifically the tissue that meets between the vaginal and anal openings as this is where it is most common to experience perineal tears during vaginal delivery. The muscles at the base of the vaginal opening are also the muscles that are responsible for stretching as the head of the baby crowns during a vaginal delivery. By gently massaging and stretching these pelvic floor muscles prior to vaginal delivery we can help to prepare the tissues for birthing a baby by increasing the tissue flexibility, reduce the risk of tearing, and help parents to better tolerate this stretching during vaginal delivery.
You can begin perineal massage/stretching at any time during your pregnancy up until delivery of your baby, completing the massage daily for 10-15 minutes at a time. The massage will likely feel uncomfortable and like intense stretching, but it should not be painful. Imagine a “normal” stretching sensation that feels like you are taking your index fingers to the opposite corners of your mouth and you are gently stretching or moving your fingers apart against the opening of your mouth. This massage/stretching will feel almost like a tingling.
To do perineal massage use the pads of your thumbs right at the base of the vaginal opening and gently press each thumb pad down and outward until you feel a tingling sensation. Hold this pressure starting at 30-60 seconds until you are gradually able to work up to holding for 5 minutes at a time. Be sure to continue breathing as you perform this deep stretch. Next, still using the pads of your thumbs gently press down and out as you sweep your thumb pads outwards away from each other over the vulvar tissue creating a “U-shaped” motion. Continue this stretching motion for 30-60 seconds until you are gradually able to increase to 3 minutes at a time. Rest and repeat.
You can also have your partner perform the perineal massage for you using the pads of their index fingers.
Recommendations on How to Help Improve Discomfort at Your Scar Tissue Post-Delivery From a Pelvic Floor Physical Therapist
Here are some practical tips to improve pain at your scar tissue following delivery of your baby:
- Do scar tissue mobilization regardless of how you delivered your baby.
It usually takes 6 weeks for scar tissue to fully heal, but that doesn’t mean you can’t work on the tissue surrounding your scar before the 6 week mark!
For cesarean deliveries:
Imagine your scar is broken into four sections. Working at both sides of your scar (above and below) start by gently using the pads of your fingers and gently stretch the tissue in all directions (up, down, left, right) and hold for 30-60 seconds before releasing and continuing at the next section. You can also gently do small circles working on either side of your scar and moving gently side to side and up and down for 30-60 seconds each direction. To progress further you can start to gradually sink the pads of your fingertips deeper and deeper into your tissue surrounding the scar (once working at the surface of the skin becomes more comfortable) and repeat the same types of stretches and scar mobilization techniques mentioned above. Another trick that I recommend to clients is using silicone strips (like Scar Away) over their incision once it has fully healed over, typically around 2-4 weeks post-delivery. This will help to improve the appearance of your scar.
For vaginal/pelvic opening deliveries:
Similar to cesarean scar tissue, you can gently work on both sides of your scar (left and right) using the pads of your fingers and gently stretch the tissue in all directions (up, down, left, right) and hold for 30-60 seconds before releasing. You can also start to gradually sink the pads of your fingertips deeper and deeper into your tissue once working at the surface of the skin becomes more comfortable.
2. Use Silicone Strips Over Your Cesarean Scar Tissue.
Silicone Strips can help to soften, flatten, and fade your scar tissue by improving hydration and collagen production which helps to improve scar tissue healing. You can begin using silicone scar strips or silicone gel (like ScarAway) over your incision around 2-4 weeks post-surgery or once your incision is fully healed. You should begin wearing the silicone strips starting at 12 hours a day or as tolerated and gradually increase wear to 23 hours a day. Each sheet can generally be worn and washed for 7-10 days total until it will need to be replaced (or it can be replaced if it is no longer adhering to the skin). Try using silicone scar gel when not actively wearing a silicone scar sheet. You should begin to see improvements in the appearance of your scar within 4-8 weeks.
3. “Splint” over your cesarean section scar to improve discomfort!
Sometimes performing activities that increase your intraabdominal pressure, like coughing and sneezing, can be incredibly painful at the site of your incision(s) after abdominal surgery. This is because of all of the layers of connective tissue that were cut during the procedure. You can do a “splint” over your abdominal scar or gently hold a pillow over your incision with different activities such as coughing, sneezing, laughing, getting in and out of bed or out of a chair, going up and down stairs, and going to the bathroom to have a bowel movement or urinate.
4. See a pelvic floor therapist if you’re struggling.
You don’t have to wait until your six week postpartum checkup to seek additional help from a pelvic floor specialist and can start addressing any symptoms you may be struggling with as soon as you feel ready. All recommendations provided above are general recommendations and not a one-size fit all solution for everyone.
Websites that I frequently recommend to help find a skilled provider near you for specialized treatment interventions tailored to you and your symptoms are pelvicguru.com and pelvicrehab.com. Checking Dr. Google for local providers always works, too.
Just know that there are treatment options available to you if you are struggling…you don’t have to “just live with things” or accept your symptoms as “a normal part of having children.”
Have questions or feeling on the fence about whether or not pelvic floor physical therapy is for you? If you’re looking for perinatal or postpartum pelvic floor treatment and you’re located in Durham, North Carolina I would love to work with you!
Reach out to me at www.floraphysicaltherapy.com to tell me a little more about what is going on so we can chat more and get the process started. Live outside of the state of North Carolina? I also offer virtual appointment options to provide more accessible care to those seeking out pelvic floor treatment for postpartum pelvic floor care.
About the author. Dr. Brook Orvis (she/her) is a Board-Certified Women’s Health and Pelvic Floor Physical Therapist, Duke Residency-Trained in Women’s Health, and the owner of Flora Physical Therapy. As a momma to a spirited toddler, she understands the difficulty of being a parent while prioritizing self-care, including caring for your body and pelvic floor.
She believes that pelvic floor therapy is for everyone and is passionate about providing accessible treatment options for birthing people, men, women, kids, and the LGBTQIA+ community so that they can take better care of themselves and receive equitable care. She loves educating and empowering clients to take charge of their body and health and to not accept leaking of urine, prolapse, pelvic pain, pain during sex, and core weakness as a normal part of being a human.
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